Provider Demographics
NPI:1114977790
Name:DESIRAJU, MADHUSHREE (MD)
Entity Type:Individual
Prefix:
First Name:MADHUSHREE
Middle Name:
Last Name:DESIRAJU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4127
Mailing Address - Fax:904-697-5102
Practice Address - Street 1:9145 NARCOOSSEE RD STE 103
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-5768
Practice Address - Country:US
Practice Address - Phone:407-243-2040
Practice Address - Fax:407-243-2043
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78762208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258496400Medicaid
591859126OtherTAX ID